Flexibility

1. Flexibility Definition The ROM available in a jt. or group of jts. The ability of a m. to relax & yield to a stretching force. The freedom or ability to move part or parts of body in a wide R of purposeful movs at the required speed. The ability to move a jt. Through a normal ROM with undue stress to musculo-tendinous unit.

2. Flexibility • Extensibility of periarticular tissues to allow normal motion of a joint. or a limb. * Hypermobility • The ROM in excess of the accepted normal in most of joints. (may be normal) * Laxity • Excessive jt. instability & abnormal motion of a given joint. (pathological)

3. Types of Flexibility • Ballistic Flexibility: Normal ROM associated with bouncing & rhythmic movements. • Dynamic Functional Flexibility: Activities that need certain angle to certain joints. & particular patterns (usual activities).

4. Factors Affecting Flexibility • Wrong habits: ↓flexibility sitting for a long period (in school, watching TV, computer work, sedentary games) • Good habits: →↑flexibility. • Genetic factors: females > males. • Hormonal factors: females> males. • Body build proportion & ↑ height → ↑flexibility . • Body wt. ↑ → ↓flexibility • Age: flexibility changes during a certain age ↑2 - 6 y ↓ 6 - 12 y ↑18 - 22 y ↓35 - up • Skills &sport activities→↑flexibility.

5. Contractile & Non-contractile Tissue • Contractile • Ms • Non-contractile • Skin • CT • Ligaments • Tendons • Capsules • Synovial Membrane

6. *N.B. • Soft tissues that can restrict joint motionare: • Skin • CT, tendons, ligaments • Ms Each one has unique qualities affecting its extensibility (ability to elongate). • Factors affecting soft tissues lengthening: • Velocity of stretch force • Intensity of stretch force • Duration of stretch force • Mechanical properties of contractile & non-contractile tissues • Neuro-physiological properties of contractile tissues

7. When soft tissue is stretched, either elastic or plastic changes occur • Elasticity Ability of soft tissue to return to its resting length after passive stretching. • Plasticity Tendency of soft tissue to assume new & greater length after the stretch force has been removed. • Both contractile & non-contractile tissues have elastic & plastic properties.

8. Degrees of Deformity • 1st degree (grade I): can be corrected actively (shortness). • 2nd degree (grade II):can be corrected passively (shortness). • 3rd degree (grade III):can’t be corrected neither activelynor passively (contractures).

9. Indications of Stretching • Limited ROM due to adhesions & scar tissues formation leading to shortening of Muscles, CT & Skin. • Prevention of structural (neglected soft tissue →shortening →structural limitations →skeletal deformities (prophylactic intervention) • When contractures interfere with every day functional activities or nursing care. • When there’s muscle weakness & opposing tissue tightness. * Tight muscle must be elongated before weak m. can be effectively strengthened.

10. Goals of Stretching 1.To regain or re-establish normal joint. ROM & mobility of soft tissue surrounding a jt.. 2. To prevent irreversible contractures. • To ↑ general flexibility of a part of the body prior to vigorous strengthening excerises. 4. To prevent or minimize risk of musculo-tendinous injuries related to specific physical activities & sports.

11. Precautions to Stretching • Don’t passively stretch (force) a joint beyond its normal ROM (Remember that normal ROM varies among normal individuals). • Newly united # should be protected by stabilization between # site & the joint where motion takes place. • Extra caution in pts. with known or suspected osteoporosis due to: • Disease b. Prolonged bed rest c. Aging d. Prolonged use of steroids (cortisone) • Avoid vigorous stretching of muscles & CT that have been immobilized over a long period of time. CT (tendons & ligaments) lose their tensile strength after prolonged immobilization.

12. Precautions to Stretching • High intensity, short duration procedures→ traumas → soft tissue weakness • Stretching should be low intensity for long duration stretch. • Strengthening excerises should be added to stretching program at some point, so patient will be able to develop appropriate balance between flexibility & strength.

13. Acute infections. Signs of inflammation. Pain at the site to be stretched. Osteomyelites (acute stage). Bone tumors. Advanced osteoporosis. 7. Severe spasticity. 8. Pain that isn’t yet evaluated by the PT or physician. Joint laxity (hypermobility). 10. Joint subluxation. 11. Joint dislocation. 12. Joint fusion. 13. Joint deformity. 14. Tissue adhesions (contractures). 15.Acute Traumas Contraindications to Stretching

14. Principles of Stretching • Consider the best stretching type to ↑ ROM. • Explain goals of stretching to the pt. • Position the pt. in a comfortable relaxed pos. → allow the best plane of motion to conduct stretching. • Free the area from restrictive clothing, bandage, splints. • Apply superficial heating to the soft tissues to be stretched. • It will ↓ possibility of injury. • Stretch direction is done opposite to tightness. 7. The pt. must be completely relaxed throughout stretching ,employ relaxation techniques before stretching.

15. Stretching movs. or exs. are performed at least 3 times/week to maintain flexibility. Progress to daily stretching routines. • 1-3 repetitions of each stretch must be done. The No. of repetitions can be ↑if the goal is to↑ROM. 10. Degree of stretch can be ↑or↓ depending on time of stretch & external force applied. 11. Tension produced shouldn’t cause pain, the pt should only feel a slight tension, which ↓ with stretching. (due to adaptation) 12. Stretch ↑gradually, building to a max. as the tissues release. 13. Stretch should be removed gradually to prevent rebouncing ortighteningof the ms.

16. Stretching depends on: • Type of stretching force. • Intensity. • Duration • Velocity.

17. Types: A. Passive Stretching • PT applies an external force & controls stretch 1direction, 2speed, 3intensity & 4duration to the tight m.. • Don’t confuse between: • Passive stretching→ elongation of soft tissues beyond full R of restriction. • Passive ROM exs.→ applied within the unrestricted(available)ROM. • Pt. must be completely relaxed during passive stretching. • Time of stretch force is usually 15 : 30 sec& repeated several times during ex. session.

18. 1. Manual Passive Stretching • Usually considered a short-duration stretch. • No specific No. of secs. are determined to be the most effective duration. • In a study to stretch hip abd. of healthy subjects15, 45sec & 2 min at the same speed → no difference. • Intensity & duration of stretch depend on: • Pt’s tolerance • PT strength & endurance • Low intensity, long duration manual stretch is more comfortable & tolerated by pt.

19. MANUAL PASSIVE STRETCH HIGH INTENSITY STRETCH Maintained versus Ballistic Stretch Inhibit stretch reflex & ↓Muscle tension Facilitate muscle contraction & ↑ tension

20. 2. Prolonged Mechanical Stretch • Low intensity external force (5-15 lb) (2: 6 kg) applied to shortened tissues over a prolonged period by mech. equipments. • Stretch force is applied through positioning with weighted traction, pulley system, dynamic splint & serial casts. • Prolonged stretch may be maintained for 20-30 min. or longer → effective stretch &↑ ROM (low intensity mechanical stretch). • Comparing long-duration mech. stretch & manual passive stretch ( the latter is rather short & there’s transient & temporary achievement of ROM).

21. Examples • Bohannon evaluated the effectiveness of an 8 min mechanical hamstring stretch compared to a 20 min or longer using overhead pulley system. The 8 min stretch resulted in a small ↑ in hamstring flexibility, which was lost in 24 hrs. It was suggested that 20 min or longer stretch is more effective to ↑ ROM & has a more permanent basis. • Use of tilt table-wedge board standing for 30 min/daily →↑ dorsiflexion in neurological pts. • Dynasplint (dynamic splint) → prolonged low intensity stretch of elbow, wrist, knee & ankle → ↑ ROM. • Low intensity prolonged stretch of 5-12 lb applied for 1 hr/daily has been found to be more effective than manual passive stretch over a 4-week period with pt’s with bilateral knee flexion contractures. It is more comfortable

22. Permanent lengthening (Plastic changes in contractile & non-contractile tissues)has been reported with long duration stretch. • The term “Permanent lengthening” means that the length is maintained after the stretching force is removed.

23. 3. Cyclic Mechanical Stretching • It is passive stretching using a mechanical devices as an Autorange using a 20-sec high intensity (up to the patient’s pain tolerance). • Intensity of stretch, • Length of each cycle, • No. of stretch cycles/minCan be adjusted with the unit. • It is similar & may be used as a useful alternative to manual passive stretching.

24. B. Active Inhibition • Is a tech. in which the patient reflexively relaxes muscles to be elongated prior to stretching maneuver. When the patyent is relaxed → minimal R to elongate the m. • It relaxes only the: - Contractile structures, - Not the CT. • The m. must be: Normally innervated and Under voluntary control. • It Can’t be used with pts having: 1. Weakness, 2. Spasticity 3. Paralysis(From a neuromuscular disease). • It Can be used in: Post-operative patient. (to avoid tightness).

25. Active Inhibition Techniques. • Contract-relax(hold-relax): Pt performs an isometric contraction of tight muscle before it is passively stretched (lengthened). M. will relax as a result of ”autogenic inhibition” (Golgi tendon organ may fire at ↓ tension). • Contract-relax-contract(hold-relax-contract). • 1st a contraction of tight muscle. • 2ndrelaxation of tight muscle. (autogenic inhibition). • 3rdconcentric contraction of opposite muscle (reciprocal inhibition of tight m.). In a study, the contract-relax-contract produced a greater ↑ in ankle dorsiflexion > contract-relax tech. (in short calf m ). * Both techs produce ↑ ROM > manual stretching.

26. 3. Agonist Contraction • Agonist= muscle opposite to the tight muscle. • Antagonist= Tight muscle. • Patient dynamically contracts (shortens) the muscle opposite to the tight muscle against resistance → reciprocal inhibition of tight muscle.

27. C. Self-Stretching • Is a type of flexibility excerises. the patient carries out by himself. • Pt. may passively stretch his tightness by: • His/her own body weight. (&gravity) • Active inhibition. • Manual passive stretch (using sound limb)

30. Peripheral joint mobilization Definition: Peripheral joint mobilization (PJM) is the use of skilled graded forces to mobilize joints:to improve motion & normalize joint function.

31. Mobilization Techniques are used to • Improve jt. nutrition. • Improve m. spasm & tension • Reduce pain. • Reverse jt. hypomobility. • Improve or restore motion. • Treat jt. dysfunction as stiffness.

32. The PT should recognize • When the mobilizing techniques are indicated (at any ROM), or • If other stretching techniques are more effective (stretching, stretching ex’s or CTM) To regain the lost motion

33. A. Joint Mobilization • Is a type of passive mov performed by the PT at a speed slow enough that the pt. can stop the mov. • The tech. may be applied with:1. Oscillatory motion or 2. Sustained stretch to • ↓Pain or • ↑mobility. • The tech. may use: • Physiologicor • Accessory movs.

34. Physiologic movements Movs. that the pt can perform voluntarily as flex, ext, abd, add & rot. 2. Described as (Osteokinematic). i.e. mov of bones in relation to each others Accessory movements Movs within the jt & surrounding tissues that are necessary for normal ROM,can’tbe doneby pt. 2. Described as a.Component motionsb.joint play. Mobilization Techniques

35. Accessory motions Motions that accompany active mov, but Aren’t under voluntary control Component mov is the often used term with accessory mov. As: upward rot. of scapula & clavicle occurring in sh. flex. B. Joint Play Motions that occur in jts & distensibilityorgive in of the jt capsule, which allow bones to move. Are necessary for normal functioning through the ROM. Can be demonstrated passively, Can’t be performed actively by the pt. Include:distraction, sliding, compression, rolling, spinning of the jt surfaces. Arthrokinematic is used to describe these motions of bone surfaces within the jt. Accessory motions

36. B. Manipulation • Is a passive movusing physiologicoraccessory motions.It may be applied:1. With a thrust , (cyropractic) or 2. Under anesthesia

37. THRUST A sudden mov performed with a high velocity. Without anaesthesia. Short amplitude motion, can’t be prevented by the pt. Performed At end of pathologic limit(end of available ROM, when there’s restriction). Using:1. Physiologic, or 2. Accessory movs. Effects: 1. Snaps adhesions. 2. Stimulates jt receptors. MANIPULATION UNDER ANAESTHESIA Medical procedure used to restore full ROM by breaking adhesions surrounding jt. With anaesthesia. Performedthrough:1. Rapid thrust, or 2. Passive stretch. Using:1. Physiologic, or 2. Accessory movs. B. Manipulation

38. Factors Affecting Jt. Motion A. Jt. shape. B. Types of Motion. C. Other Accessory motions.

39. Factors Affecting Joint motion A. Joint Shape The type of motion is influenced by jt. shape. • Ovoid: one convex surface & one concave (as A). • Sellar(Saddle):one surfaceis concave in one direction & convex in the other, with the opposing surface convex& concave (as a horse back rider) (as B).

40. B. Types of Motion • When a bony lever (bone)moves about an axis of motion→mov of bony surfaces on the opposing bone surface within the jt. i.e. • Movement of bony lever- Called swing as (flex, ext, add, abd & rot.) - Measured in degrees. - Called ROM. 2.Motion of the bony surfaces- Within jt is a combination of rolling, sliding & spinning. - These accessory motions allow greater angulation of bone as it swings. - This needs adequate capsule laxity or jt. play.

41. a. Roll • One bone rolls on another. The surfaces are incongruent. • New points on one surface meet new points on the opposing surface. • Results in angular motion. • Always rolling occur in the same direction of the mov., whether the surface is convex or concave. • There’s compression of the surface on the side to which the bone is angulating & separation on the other side. • In normal functioning jts, pure rolling doesn’t occur alone, but in combination with sliding & spinning.

42. b. Slide • One bone slides across another. • For pure slide, the surface must be congruent either flat or curved. • There’s no pure slide as jt surfaces aren’t completely congruent. • Same point on one surface comes into contact with new points on the opposing surface. • Direction of slides depends on whether the surface is convex or concave.

43. If the moving surface is convex → Sliding is in the opposite direction of angular mov. • If the moving surface is concave →Sliding is in the same direction as the angular mov. • This mechanical relationship is known as convex-concave rule. It determinesthe direction of the mobilization force, when jt mobilization gliding techniques are used.

44. c. Combined roll-sliding in a joint • The more congruent the jt surface → the more sliding of one bony partner on the other with movs. (e.g. metatarsals & metacarpals) • The more incongruent the jt surface → the more rolling movs. (e.g. hip & sh)

45. Sliding Is used to ↓ Restore jt. play Reverse jt. Hypomobility Rolling Is not used, as ↓ Jt. Compression E.g. hip abd &add sh abd &add For Joint Mobilization Techniques

46. When PT passively moves the articulating surface in the direction in which the slide normally occurs→ Translatory glide (glide) ↓ used to 1.Control pain or 2.Stretch capsule If applied gently If with stretch force

47. d. Spin • Rotation of one bony segment about a stationary mechanical axis. • Spinning rarely occurs alone, but in combination with rolling & sliding. • 3 examples of spinning in the body jts: • Sh.: with flex/ext. • Hip: with flex/ext. • Radio-humeral: with sup./pron. • **Knee ext either by closed or open chain

48. C. Other Accessory Motions that affect the Joint e. Compression. f. Traction (A&B).

49. e.Compression • Is the ↓ in jt space. • Occurs in LL&spinal jts with wt. bearing. • Some compression occurs as m. cont→provide stability to jt. • As one bone rollson the other, some compression occurs on the side to which the bone is angulating. • Normal intermittent compression loads→ help in moving synovial fluid so → maintain cartilage health. • Abnormal high compression loads→articular cartilage changes & deterioration.(friction → erosion & OA)

50. f.Traction • Distraction or separation of jt surfaces. • For distraction to occur, the surfaces must be pulled apart. The mov isn’t always the same. • Pulling on the long axis of one bone(as pulling the shaft of humerus →glide jt surface) (long axis traction). • Distraction of gleno-humeral jt requires a pull at a 90° to the glenoid fossa → distraction & jt traction or jt separation. • Distraction is used to: • Control or relieve pain: If applied gently. • Stretch the capsules: If applied with stretching force.